IDENTITY and STATEMENT OF EDUCATIONAL PURPOSE

2015-2016
Office of FINANCIAL AID
IDENTITY and STATEMENT OF EDUCATIONAL PURPOSE
PO BOX 468 ● POCAHONTAS, AR 72455 ● (870) 248-4000 ● FAX (870) 248-4100
** STOP!! DO NOT SIGN THIS FORM UNLESS you are in the BRTC Financial Aid Office or presence of a Notary **
As a federal aid recipient, you are required verify your identity by completing the Statement of Educational Purpose below
IN PERSON at Black River Technical College
-OR- in the presence of a Notary - then, submit to BRTC Financial Aid Office.
You must provide along with THIS FORM: A copy of a valid government-issued photo identification (ID),
a driver’s license, other state-issued ID, or passport
- OR -
Statement of Educational Purpose
I certify that I ___________________________ am the individual signing this Statement of Educational
(Print Student’s Name)
Purpose and that the federal student financial assistance I may receive will only be used for educational
purpose and to pay the cost of attending Black River Technical College for 2015-2016.
______________________________________________
__________________
Student’s Signature
Date
______________________________________________
Student’s BRTC ID Number or SSN
______________________________________________
___________________
BRTC Financial Aid Office Representative
Date
Notary’s Certificate of Acknowledgement (complete ONLY if a BRTC Financial Aid Officer is not present)
State of ______________________________________________________________________________
City/County of_______________________________________________________________________________
On______________________, before me,___________________________________________________,
(Date)
(Notary’s Name)
_________________________________ personally appeared and provided to me on basis of satisfactory
(Student Name)
evidence of identification_______________________________________ to be the above-named person
(Type of government-issued photo ID provided)
who signed the foregoing instrument.
Witness my hand and seal
______________________________________________
(Notary signature)
(seal)
My commission expires on _______________________
(Date)
Por favor, vuelta a la página para la versión en español.
2015-2016
Office of FINANCIAL AID
IDENTITY and STATEMENT OF EDUCATIONAL PURPOSE
PO BOX 468 ● POCAHONTAS, AR 72455 ● (870) 248-4000 ● FAX (870) 248-4100
Como beneficiario de la ayuda federal que son necesarios para verificar su identidad, completando la
Declaración de Propósito Educativo a continuación
en persona en Black River Technical College O en la presencia de un notario.
Usted debe proporcionar junto con ESTE FORMULARIO: una copia de un documento válido
identificación con foto emitida por el gobierno o una licencia de conductor, otro estado identificación
emitida, o pasaporte.
Declaración de Propósito Educativo
Certifico que yo, __________________________, soy el individuo que firma esta
[Imprimir Nombre del Estudiante]
Declaración de Finalidad Educativa y que la ayuda financiera federal estudiantil que yo
pueda recibir, sólo será utilizada para fines educativos y para pagar el costo de asistir a
Black River Technical College para 2015–2016.
_____________________________________________
[Firma del Estudiante]
________________
[la Fecha]
________________________________
[Número de Identificación del Estudiante]
Notary’s Certificate of Acknowledgement (Si no se ha hecho en persona en)
State of ______________________________________________________________________________
City/County of_______________________________________________________________________________
On______________________, before me,___________________________________________________,
(Date)
(Notary’s Name)
_________________________________ personally appeared and provided to me on basis of satisfactory
(Student Name)
evidence of identification_______________________________________ to be the above-named person
(Type of government-issued photo ID provided)
who signed the foregoing instrument.
Witness my hand and seal
______________________________________________
(Notary signature)
(seal)
My commission expires on _______________________
(Date)